Cost-effectiveness of Tenecteplase Versus Alteplase for Acute Ischemic Stroke in Canada Based on the AcT Trial

BACKGROUND: Tenecteplase is a genetically modified variant of alteplase that is administered as an intravenous bolus and has greater fibrin-specificity and a longer half-life. Data from the Alteplase compared to Tenecteplase (AcT) trial showed non-inferiority of tenecteplase compared to alteplase in patients with acute ischemic stroke (AIS) treated within 4.5 hours of symptom onset, with the direction of effect favoring tenecteplase. Based on this evidence, the Canadian Stroke Best Practice Recommendations added tenecteplase as an alternative to alteplase. Its cost-effectiveness in the Canadian setting, however, remains to be determined. METHODS: A cost-effectiveness analysis of tenecteplase versus alteplase for AIS in the Canadian setting was performed. The model combined a decision tree for the 90 days post-index stroke, where patient distributions across seven modified Rankin Scale states were informed by the AcT trial, and a Markov model for the remainder of the lifetime horizon. Cost-effectiveness was assessed as the incremental cost per quality-adjusted life-year (QALY) gained. RESULTS: The analysis demonstrated tenecteplase to dominate alteplase (i.e., produced 0.138 more QALYs and ＄877 savings per AIS patient). Tenecteplase dominance was achieved as early as 90 days post-AIS and confirmed by numerous sensitivity/scenario analyses. CONCLUSION: This analysis represents the first to assess the cost-effectiveness of tenecteplase as an alternative to alteplase in the treatment of AIS in the Canadian setting. Though all benefits related to its simplified bolus administration were not considered, results robustly demonstrate tenecteplase represents a high-value strategy. Together with the accumulating clinical evidence, this study may help support decisions to adopt tenecteplase on hospital formularies.